Ramblings of an Emergency Physician in Texas

The ‘wrong’ fluid

I was presented with a female patient whom every female nurse who saw her said ‘…she looks like she’s going to have quadruplets…’.

History: several months of abdominal distension, slowly, to the point that she now has trouble breathing, and is at the end of her psychological rope. Signficantly, the patient is in her early forties, no other medical history, and was told to stop drinking recently "because you’re killing yourself".

Exam: Pretty unremarkable except for a way-past-term size distended and tense abdomen. Patient is uncomfortable but not toxic. So, for diagnostic and therapeutic purposes, let’s get some fluid out of this abdomen. I do this routinely, so, no biggie. RBA discussed, etc. I did a bedside sono and confirmed the area chosen to start had no adherent bowel, etc.

Procedure started. Hmm, this fluid looks really really dark, and not like any cirrhosis fluid I’ve gotten before. For a brief second I wonder if I’m in her colon despite the sono, but given the rate and copious nature (six liters, and plenty left where that came from) it’s not colon. But it’s not ‘right’, either.

A CT is ordered. And resulted. "Massive ascites, a 40x20x13cm pelvic mass, with some others, ‘of ovarian origin, probably cystadenocarcnoma’…".

Good news, not cirrhosis. Bad news: cancer. It was a malignant ascites. The patient took the news with more equanimity than I was expecting. A GYN oncologist was consulted, and the patient admitted for a long and arduous course of probable surgery and chemotherapy.

The crux of this case was having done a lot of paracenteses for cirrhosis and knowing that the fluid from this one was ‘wrong’, spurring a more through ED workup. Sometimes experience helps. That was my most interesting patient this week. And it’s only Tuesday.

Strange, I had a patient last week with abd pain, grossly distended. CT showed a 47x25x25 ovarian mass. Not a tricky diagnosis as the abd felt hard as a rock. Funny thing, she had just seen a GI doc for same compaint. He scoped her and told her she had an ulcer. Go figure.

Thank you for following up on your patient, and having the experience (& being awake enough) to recognize more workup was needed on the patient. Being a family member of people who have been misdiagnosed and inadequately treated in both Colorado and Texas medical clinics, I have very little regard left for physician office clinics. I have seen far better, more accurate treatment in ER’s. Maybe that is partially because you have qualified staff in your ER, stay more up-to-date, or are just a ‘different’ class of physician than the 10 minute visit clinic docs.